Dr. Schneider will be speaking at the Becker's 16th Annual Future of Spine + The Orthopedic, Spine and Pain Management-Driven ASC Conference. To learn more and register, click here.

Question: What are the major issues in pain management today and how are you handling the obstacles? 
 
Dr. Philip Schneider: There are many important issues in pain management. It's not just an opioid crisis. There is illegal activity which needs to be addressed, both through law enforcement and through counseling, education and supportive treatment. However, that should not be confused with the legitimate needs of our patients. Our patients' needs should not be compromised. There is good, robust medical evidence that opioids are effective. However, new regulations require us to manage this in a different way. The critical issue involves some de-escalation of opioids along with using other modalities for pain control.

These other modalities might involve multi-modal drug treatment, cognitive and behavioral therapy, interventional pain management and additional physical therapy.  The problem is that it takes more time for the physician to implement these other modalities, and it also costs more money. Doctors don't get paid for this extra workload. Additional physical therapy is not always realistic because of caps on physical therapy and the high costs of co-pays. Cognitive and behavioral therapy is often poorly covered or not covered by insurance companies. Multi-modal drug treatment can be too expensive for our patients to afford; Lyrica, Lidoderm patches, liposomal bupivacaine and IV acetaminophen come to mind.

Strategies to ease the workload include delegating these activities to physician assistants, nurse practitioners and to some extent, medical assistants. However, that also has a cost attached to it.

The use of opioid prescribing algorithms has also helped [fight opioid abuse]. Our orthopedic practice of 177 physicians, The Centers for Advance Orthopaedics, has created opioid prescribing clinical pathways. It has become easier to do some of these [techniques] with a standardized approach. We also monitor our physicians to ensure compliance with the pathway. We have also established multi-modal drug protocols for our surgical patients, which include acetaminophen, Celebrex, Lyrica, ketamine, decadron and bupivacaine in addition to the opioids. Opioid use has dropped dramatically in this approach.

Q: Do you believe most clinicians who prescribe opioids are properly educated in addiction medicine? How have your opioid prescribing patterns changed in recent years?

PS: Most clinicians have been going through recent courses regarding opioid prescribing. It is now required by many state licensure boards. It is also required by many medical malpractice carriers. Virtually, every medical meeting has some topic addressing this issue. While that was not the case in the past, it is being rapidly corrected. Addiction medicine is an entirely different issue. Most of us are not trained in this and may not have interest in addiction medicine. It is important to be knowledgeable on addiction medicine, but it is probably best to refer this out to an addiction specialist. That is part of our opioid prescribing clinical pathway.

Regarding my opioid prescribing patterns, it has completely changed. I now check our state drug monitoring data base (CRISP); I do urine drug screens; I have in-depth conversations with my patients regarding risk and addiction; I have my patients sign opioid agreements; I administer opioid risk assessment tools; I check for sleep apnea issues and I use multiple other tools for pain reduction. Nothing I do is the same.

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